ARTICLE IN PRESS. Bülent Kadri GÜLTEKİN 1, İ. Ferhan DEREBOY 2 INTRODUCTION

Transcription

1 Turkish Journal of Psychiatry 2011; 22( ) The Prevalence of Social Phobia, and its Impact on Quality of Life, Academic Achievement, and Identity Formation in University Students ARTICLE IN PRESS Bülent Kadri GÜLTEKİN 1, İ. Ferhan DEREBOY 2 SUMMARY Purpose: The present study aimed to determine the prevalence of social phobia, and the sociodemographic variables, substance use patterns, and comorbid psychiatric disorders associated with it. The impact of social phobia on quality of life, academic achievement, and identity formation were also examined. Materials and Methods: The study was conducted between 01 March and 01 June 2008, and included 700 undergraduate students at Adnan Menderes University. A sociodemographic data form, the Liebowitz Social Anxiety Scale (LSAS), World Health Organization Quality of Life-Brief Form, Turkish Version (WHOQoL-BREF-TR), and Instrument for Assessing Identity Confusion (IFAIC) were administered to the participants. Findings: In all, 20.9% of the participants had social phobia during the previous year and 21.7% had social phobia for a lifetime. In total, 74.6% of those that had social phobia during the previous year and 76.5% of those that had social phobia for their whole lives also had a specific social phobia. There was a significant difference between the participants with generalized social phobia or a specific social phobia, and those without social phobia, in terms of LSAS and IFAIC scores. Logistic regression analysis showed that the risk of social phobia was 1.7-fold higher among the females than males, 1.5-fold higher among those that lived in cities for the last 15 years than those that lived in towns, 1.9-fold higher among those that lived in cities for the last 15 years than those that lived in villages, and 1.8-fold higher among those that had relatives with a psychiatric illness than those that didn t. Higher socioeconomic status was negatively correlated with the prevalence of social phobia. Cigarette smoking was more prevalent among the students without social phobia and suicidal ideation was more prevalent among the students with social phobia. WHOQOL- BREF-TR scores showed that students without social phobia had significantly higher quality of life quality than those with social phobia. Selfreported academic performance did not significantly differ between the students with social phobia and those without social phobia. Conclusion: Social phobia research may be limited, but was highly prevalent among the university students in the present study and had significant negative effects on identity formation and quality of life. Key Words: Social phobia, university students, life quality, academic achievement, self-development. INTRODUCTION Social phobia (social anxiety disorder [SAD]) is characterized by constant fear of embarrassment and humiliation in social situations in which an individual feels as if he/she is being observed by others. According to DSM-IV (American Psychiatric Association 1994), people with social phobia avoid fear-evoking social situations or participate in them with intense anxiety. An irrational fear of being evaluated by others is the most important clinical feature of social phobia (Dilbaz et al. 2001). A growing number of researchers and clinicians have become interested in social phobia in recent years. Data from a growing body of research on social phobia shows that its prevalence in high and that it negatively affects quality of life. Epidemiological studies from the USA show that 13% of Americans have social phobia, which makes it the most prevalent generalized anxiety disorder and the 3rd most common psychiatric disorder after major depressive disorder and alcohol addiction (Last et al. 1992; Kessler et al. 1994). The Received: Accepted: Uzm., Bolu İzzet Baysal Mental Hospital, Bolu, 2 Prof., Adnan Menderes Univ, Department of Psychiatry, Aydın. Bülent Kadri Gültekin MD, gultekinb@yahoo.com 1

2 Turkish Mental Health Profile (Kılıç et al. 1997) reported that the prevalence of social phobia was 1.8% for the last 12 months prior to the time of the study. Other Turkish studies that included university students reported that the prevalence of social phobia is between 9.8% and 22% (Kırkpınar et al. 1997; İzgiç et al. 2000; Dilbaz et al. 2002). There are differences between social phobia patients, in terms of the number and types of social fears, frequency of avoidant behavior, level of functionality in daily life, sociodemographic factors, self-esteem, and therapeutic requirements. There were many discussions about how to determine the subtypes for social phobia according to these differences. The most common approach to social phobia suggests that there are specific and generalized subtypes. Specific social phobias are characterized by avoidance of specific social situations. Generalized social phobia is characterized by avoidance of many social situations. Patients with generalized social phobia fear interpersonal interactions and avoid social situations in which they think they will be observed or evaluated (Heimberg et al. 1993; Boone et al. 1999; Eng et al. 2000). 90% of the people with social phobia fear public speaking, which is a very common symptom of both subtypes of social phobia. Public speaking¾a common activity in many educational settings¾is a very anxiety-provoking activity. Among the general population, 15%-30% report that they feel very anxious when they are talking to a group of people (Kessler et al. 1998; Furmark et al. 1999; Stein et al. 2000a). The major risk factors for social phobia include low socioeconomic status, never being married, unemployment, lowlevel education, lack of social support during the onset of the illness, trauma, and genetic predisposition (Wittchen et al. 2001). It is very important to identify high-risk groups and situations for early intervention. Among people with social phobia diagnosis of lifetime comorbid psychiatric disorders, such as depression, other anxiety disorders, and substance abuse, is very high (Kessler et al. 1999; Mennin et al. 2000). The results of a social phobia study that included adolescents showed that the lifetime prevalence of the disorder was 5%- 15% (Heimberg et al. 2000). The age of onset of social phobia is lower than that for other anxiety and mood disorders, which makes it a more important disorder for children and teenagers (Schneier et al. 1992). During higher education period, which usually corresponds to late adolescence, the individual wants others to accept his/her independence and acknowledge his/her adult identity. During this period the quality of the impressions they make on others in social situations is very important to them. This is why they have high expectations of themselves. If an individual cannot fulfill such expectations, the level of social anxiety increases and the signs of social phobia become evident. In addition, upon starting higher education, the adolescent finds himself in a very social environment. If an individual cannot manage to socialize in such an environment, such symptoms as not being able to deal with negative situations in the future, failing to develop self-confidence, and the emergence of identity crisis can occur (Dereboy 1993). For long years, health care specialists ignored the effects of mental disorders, especially anxiety disorders, on quality of life, focusing mainly on ameliorating symptoms. Recently, the importance of quality of life has been emphasized, which has led to an increase in the number of studies on social phobia. Consequently, it was observed that social phobia has negative effects on quality of life. Social phobia tends to affect all the critical aspects of one s life. Individuals with social phobia have severe difficulty professionally, as well with school and social-emotional relationships. Students with social phobia have difficulty speaking in front of a group of people, and fail or drop out of high school/ university due to anxiety (Van Ameringen et al. 2003). Thus, early diagnosis and intervention will increase their level of enjoyment of school and their high school/university graduation rates, which consequently will help them to become productive individuals. There is a limited number of studies on the prevalence and causative factors of social phobia in Turkish university students. No study has investigated the effects of social phobia on academic performance, quality of life, or identity formation. The present study aimed to determine the prevalence of social phobia among university students, its relationship with several variables, and its effects on substance abuse, suicidal ideation, identity formation, academic performance, and quality of life. METHOD AND MATERIALS Participants This cross-sectional study included 7935 undergraduate students at Adnan Menderes University during the academic year. With a confidence interval of 95%, standard deviation of 0.02, and social phobia prevalence of 10%, the number of participants was calculated to be 864. As such, 864 students were selected as the study group using systematic sampling. Students with an Associate Degree were excluded, as they continued their education in different towns of Aydın. The Adnan Menderes University Medical School Ethics Committee approved the study protocol and written informed consent was provided by the participants. In all, 20 students from the medical and nursing schools completed the questionnaires beforehand and the questions were evaluated and re-arranged accordingly. The study was conducted between 01 March and 01 June In all, 700 (81.01%) of the 864 students participated in the study. The remaining 164 students did not participate 2

3 in the study because they could not be contacted twice or did not want to participate. Diagnoses were made during psychiatric evaluations according to DSM IV-TR (American Psychiatric Association 2000). Those with social phobia in 1 area were diagnosed as having a specific social phobia and those with social phobia in more than 1 area were diagnosed with generalized social phobia. Sociodemographic data form A 24-item sociodemographic data form was used to determine the sociodemographic profiles of the students, including age, gender, living arrangements, level of education, level of income, etc. Liebowitz Social Anxiety Scale (LSAS) The LSAS (Liebowitz, 1987) was designed to evaluate the fear and/or avoidant behavior of people with social phobia during social relationships and performances. The scale includes 24 items and 2 subscales. The first subscale has 11 items and investigates social relationships. The second subscale has 13 items and investigates performance. The 4-point Likert-type scale measures the intensity of fear and avoidant behavior during the previous week. The total score is obtained by adding the fear and avoidant behavior scores. Dilbaz and Güz (2001b) studied the scales reliability and validity in Turkey and reported its internal validity as (Cronbach s alpha) The correlation coefficient between researchers was r = The Turkish version of LSAS is objective, valid, and reliable for measuring the severity of social phobia and related findings in the Turkish population. World Health Organization Quality of Life-Brief Form, Turkish Version (WHOQoL- BREF-TR) Eser et al. (1999) conducted the reliability and validity study of the WHOQoL-BREF-TR. The Turkish version of the form had an internal validity score of 0.83 (Cronbach s alpha) in physical terms, 0.66 in mental terms, 0.53 in social terms, and 0.73 in both environmental and environmental-national terms. Test-retest reliability scores for each question varied between Pearson s coefficients of 0.57 and WHOQOL- BREF includes 26 questions in 2 categories¾perceived quality of life in general and perceived health status. An additional question was added during the validity study in Turkey; WHOQOL-BREF-TR has 27 questions. Instrument for Assessing Identity Confusion (IFAIC) The Instrument for Assessing Identity Confusion (IFAIC) was developed in order to systematically investigate and evaluate factors associated with identity confusion for clinical and research purposes (Dereboy et al. 1994). It is a 28- item self-report scale. Questions are answered on a 5-point Likert-type scale. The total score varies between 28 and 140. Higher scores indicate a higher incidence of experiences involving identity confusion. In some studies the internal validity alpha coefficient for this scale was 0.90, which makes it a reliable tool for clinical assessment (Dereboy et al. 1994; Çuhadaroğlu 1999; Dereboy 1999; Türkbay et al. 2005). Statistical Analysis Data were analyzed using SPSS v Student s t test was used for 2 continuous variables, the chi square test was used for categorical variables, ANOVA (analysis of variance) was used to compare groups in terms of LSAS and IFAIC scores. Bonferoni correction was used for post hoc testing. Logistical regression analysis was used to evaluate the significance of the relationship between 2 dependant and independent variables. Pearson s correlation coefficient was calculated to evaluate the relationship between LSAS and IFAIC scores. For all the analyses statistical significance was considered a < 0.05, and for the tests shown in Tables 3 and 4 that used Bonferoni correction statistical significance was considered a < RESULTS The study included 700 students with a mean age of ± 1.76 years. In total, 332 (47.4%) were male and 368 (52.6%) were female. In all, 146 participants (20.9%) had social phobia during the previous year, whereas 152 participants (21.7%) had social phobia for a lifetime. Among the students, 74.6% that had social phobia during the previous year and 76.5% of those that had social phobia for a lifetime had a specific social phobia. Among those with a specific phobia, speaking or performing in front of an audience and speaking in a meeting without preparation were the most common anxiety-provoking social situations (Table 1). Table 1. LSAS items that students with specific social phobia (n = 112) rated as 3 on a scale of 1 to 4 LSAS Items n (%) Moving, performing, or speaking in front of an audience 88 (78.57) Speaking in a meeting without preparation 84 (75.00) Attracting attention towards oneself 56 (50.00) Looking for a romantic or sexual partner 48 (42.85) Speaking to a group of people with preparation 44 (39.28) Working while being observed 44 (39.28) Being tested on talents, capabilities, or knowledge 40 (35.71) Participants with a specific or generalized social phobia were compared to those without social phobia, in terms of LSAS and IFAIC scores using ANOVA and the difference between the 2 groups was significant. Post hoc Bonferroni analysis was used to compare groups of 2. The results indicate that the students with a specific social phobia had significantly higher LSAS social phobia, anxiety, and avoidant behavior scores than those without a specific social phobia. Students with 3

4 Table 2. IFAIC and LSAS scores. Students without social phobia (n=548) Students with a specific social phobia (n=112) Students with generalized social phobia (n=40) Analysis F* P LSAS total anxiety score ± ± ± <0.01 LSAS total avoidance Score ± ± ± <0.01 IFAIC score ± ± ± <0.01 ANOVA, (arithmetic mean ± standard deviation). *For all analyses the degree of freedom was Table 3. Participant sociodemographic data. Variable Students with social phobia n (%) Students without social phobia n (%) Analysis Χ 2 SD P Gender Male 52 (34.2) 280 (51.1) Female 100 (65.8) 268 (48.9) <0.01 Birth Order 1 56 (36.8) 228 (41.6) 2 48 (31.6) 148 (27.0) (31.6) 172 (31.4) Place of residence for the last 15 years City 77 (50.7) 356 (65.0) Town 58 (38.2) 152 (27.7) Village 17 (11.2) 40 (7.3) Mother s level of education No education 12 (7.9) 64 (11.7) Primary school 64 (42.1) 240 (43.8) Middle school 20 (13.2) 68 (12.4) High school 44 (28.9) 108 (19.7) University 12 (7.9) 68 (12.4) Father s level of education No education 4 (2.6) 12 (1.7) Primary school 52 (34.2) 216 (30.9) Middle school 12 (7.9) 96 (13.7) High school 52 (34.2) 200 (28.6) University 32 (21.1) 176 (25.1) Family history of psychiatric illness Yes 24 (15.8) 40 (7.3) No 128 (84.2) 508 (92.7) Existence of a general medical condition Yes 24 (15.8) 80 (14.6) No ) 468 (85.4) (X ± SD) (X ± SD) t SD P Number of siblings 2.70 ± ± Monthly family income (TL) 1172 ± ± <0.01 generalized social phobia had significantly higher LSAS social phobia, anxiety, and avoidant behavior scores than those with a specific social phobia. A significant difference was observed in IFAIC scores between students with a specific or generalized social phobia and those without social phobia (Table 2). Significant differences were not observed in IFAIC scores between the students with a specific social phobia and those with generalized social phobia (Table 2). LSAS social anxiety total score was positively correlated with IFAIC score and the correlation was significant (r = 0.619, P < 0.001). In total, 5 independent variables that were significantly correlated in 1 variable analysis were evaluated using logistical regression analysis. The risk of social phobia was 1.7-fold 4

5 Table 4. Logistical regression analysis for which social phobia was the independent variable. Variable Regression Coefficient Standard error P Odds ratio 95% Confidence Interval Gender (female) (male*) The place of residence for the longest time during the last 15 years (city*) The place of residence for the longest time during the last 15 years (town) The place of residence for the longest time during the last 15 years (village) Family history of psychiatric illness (negative family psychiatric history*) Family income level (TL) *Reference. Table 5. Cigarette, alcohol, and substance use, and suicidal ideation. Variable Students with social phobia n (%) Students without social phobia n (%) Analysis Χ 2 SD P Cigarette smoking yes 20 (13.2) 180 (32.8) no 132 (86.8) 368 (67.2) <0.01 Alcohol use yes 36 (23.7) 160 (29.2) no 116 (76.3) 388 (70.8) Substance use yes 0 8 (1.5) No 152 (100) 540 (98.5) Suicidal ideation None 96 (63.2) 424 (77.4) Ideation, no action 52 (34.2) 108 (19.7) Attempted suicide 4 (2.6) 16 (2.9) higher among female students than male students, 1.5-fold higher among those that lived in towns than among those that lived in cities for the longest time for the last 15 years, 1.9-fold higher among students that lived in villages, and 1.8- fold higher among those with a family history of psychiatric illness. Higher income levels were negatively correlated with the prevalence of social phobia (Tables 3 and 4). Significant differences were not observed between undergraduate departments, level of education, or the prevalence of social phobia. The incidence of social phobia was lower among the older students than among the younger students; the difference was not statistically significant. There wasn t a statistically significant relationship between birth order and social phobia. Students without social phobia had a significantly higher rate of cigarette smoking, whereas students with social phobia had a significantly higher rate of suicidal ideation. There wasn t a difference between the 2 groups in terms of the number of suicide attempts (Table 5). There wasn t a difference between the 2 groups in terms of having a girlfriend/boyfriend at the time the study was conducted (P < 0.05). WHOQOL-BREF-TR scores showed that students without social phobia had significantly higher quality of life scores in all areas than the students with social phobia (Table 6). Students with a specific social phobia had significantly higher quality of life scores in psychological and social areas than students with generalized social phobia (P < 0.05). Self-report results show that there wasn t a significant difference between students with social phobia and students without social phobia, in terms of academic achievement (P = 0.256). In all, 208 students without social phobia (38%) and 56 students with social phobia (36.8%) ranked their academic achievement as good. Table 6. WHOQOL-BREF-TR scores. Areas Students without social phobia Students with social phobia Analysis t* P Physical ± ± <0.001 Psychological ± ± <0.001 Social ± ± <0.001 Environmental ± ± <0.001 Environmentalnational ± ± <0.001 *For all analyses the degree of freedom was

6 DISCUSSION The present study aimed to determine the prevalence of social phobia among university students, and the associated risk factors and substance abuse rate. The effects of social phobia on identity formation, quality of life, and academic achievement were also investigated. The results show that social phobia was highly prevalent among the university students in the study. In addition, the difference between the prevalence of specific social phobias and generalized social phobia, and their effects on quality of life and social phobia scale scores, makes it necessary to consider these 2 disorders separately. Prevalence and Subtypes The lifetime prevalence of social phobia was 9.8% among students from Cumhuriyet University in Sivas, 22% among students from Ankara University, and 17% among students from Atatürk University (Kırkpınar et al. 1997; İzgiç et al. 2000; Kırpınar et al. 1997). Results of a study that Solmaz et al. (1999) conducted in Turkey reported social situations that make people anxious in order of intensity. Speaking in public without preparation provoked the most anxiety. Acting or performing in front of an audience was the second most anxiety-provoking situation, whereas attracting attention towards oneself was the third most anxiety-provoking situation. A study performed in Sweden in 2007 showed that the prevalence of social phobia among university students was 16.1%. The most common social phobia was public speaking. Other social phobias, including having a phone conversation with a stranger, meeting a stranger, participating in group discussions, and using public toilets, were ranked in order of intensity. In all, 83% of the participants had a specific social phobia¾a less severe form of social phobia¾whereas 17% had generalized social phobia¾a more severe disorder (Tillfors and Furmark 2007). Results of a pilot study conducted in Australia showed that the prevalence of social phobia was 18.3% among university students (Wilson, 2005). In Germany a study that included 3021 subjects aged between 14 and 24 years reported that the lifetime prevalence social phobia was 8.7%; it was reported that 33% of the participants had generalized social phobia (Wittchen et al. 1999). According to the results of a study from Nigeria that included 500 university students, the lifetime prevalence social phobia was 9.4% and the prevalence of social phobia during the previous year was 8.5%; the participants were most anxious when speaking in front of an audience (100%) or a small group (94.9%) (Bella and Omigbodun 2008). Studies from Turkey and other countries reported different prevalences of social phobia due to differences in the number of participants, methods, and diagnostic criteria; however, regardless of cultural differences, the most common specific social phobia was public speaking. Demographic variables and risk factors Social phobia was more prevalent among Cumhuriyet University students that had low socioeconomic status, were born in villages and lived in villages for the last 15 years, were female, and had a family history of psychiatric disorder in their families (İzgiç et al. 2000). A study from Sweden reported that social phobia was more prevalent among students that were female, single, born outside of Sweden, and lived in small villages (P<10.000) or in the southern parts of the country; however, the differences were not statistically significant (Tillfors and Furmark 2007). In Germany the prevalence of social phobia among adolescents and young adults was reported as 9.5% among females and 4.9% among males (Wittchen et al. 1999). In Nigeria the lifetime prevalence of social phobia was higher among women than men, but the difference was not statistically significant (10.1% among women and 8.7% among men). The prevalence of social phobia was 15.9% among lower classes and 7.3% among higher classes of the society. Moreover, the prevalence of social phobia was negatively correlated with monthly income (Bela and Omigbodun 2008). In accordance with this study, studies from Turkey and other countries reported that social phobia was more prevalent among women, people of African descent, people of low socioeconomic status, and people that belong to the lower classes of the social hierarchy, such as those living in villages. Gender roles imposed on women may be the reason for the higher prevalence of social phobia among them, as social phobia among women is accepted and desired by the society. Low socioeconomic status may cause social phobia by limiting social contact with others and lowering the self-esteem. Cigarette smoking, alcohol /substance abuse, and suicide In the present study the students with social phobia had significantly higher rates of suicidal ideation than those without social phobia; however, there wasn t a difference between the 2 groups in terms of attempted suicide. Francis et al. (1992) reported that adolescents with social phobia had higher rates of suicidal ideation. The results of a study from Germany show that adolescents and young adults with comorbid depression had significantly higher rates of suicidal ideation and attempted suicide (Stein et al. 2001). A 3-year longitudinal study that included 4796 participants aged years reported that there was an increase in suicidal ideation in social phobia, but that there wasn t a significant relationship between social phobia and attempted suicide (Saren et al. 2005). Results of the present study show that alcohol and substance use rates were similar among the students with and without social phobia. In Nigeria 10.3% of participants with social phobia and 7.5% of those without social phobia used alcohol at the time the study was conducted, but the difference be- 6

7 tween the 2 groups was not statistically significant (Bella and Omigbodun 2008). In a study from the USA that included 228 university students the results show that alcohol use was related to peer relationships and social connections, rather than to social anxiety (Ham and Hopa 2005). Results of the present study show that significantly more of the students without social phobia smoked cigarettes than those with social phobia (32.8% of the students without social phobia and 13.2% of those with social phobia). A study from Germany showed that among 3021 adolescents and young adults, the effects of social fears on the development of nicotine addiction were very important. It was reported that there was an increase in nicotine use due to the fact that it reduces anxiety in social settings and that it is considered socially acceptable (Sonntag et al. 2000). A 6-year longitudinal study that included 668 adolescents and young adults by Johnson et al. (2000) reported that there was a significant relationship between heavy cigarette smoking ( 20 cigarettes d 1 ) and agoraphobia, generalized anxiety disorder, and panic disorder; however, a significant relationship between heavy cigarette smoking, and obsessive-compulsive disorder and social anxiety disorder was not observed. In the present study cigarette smoking was less prevalent among the students with social phobia. Although there are many factors that affect the use of nicotine, we think that less exposure to social situations and less peer pressure to smoke leads to less cigarette smoking in individuals with social phobia. The effects of social phobia on identity formation, quality of life, and academic achievement Higher IFAIC scores were correlated with a higher incidence of situations associated with identity conflicts, which shows that those with social phobia, especially generalized social phobia, experienced identity conflicts more often than those without social phobia. In other words, the students with social phobia experienced more conflicts during identity formation. Students with generalized social phobia experienced more conflicts during identity formation than those with a specific social phobia. To the best of our knowledge the present study is the first to investigate the direct relationship between identity formation and social phobia. Dereboy et al. (1994, 1999) reported a statistically significant relationship between IFAIC score and self-reported psychological problems, as well as low Rosenberg Self-Esteem Scale scores among adolescents. The prevalence of social phobia among Cumhuriyet University students with low self-esteem was 14.9% and 6.6% among students with high self-esteem; the difference between the 2 groups was statistically significant. The results of that study also show that students with social phobia had significantly higher Rosenberg Self- Esteem Scale scores than those without social phobia (higher scores indicate lower self-esteem) (İzgiç et al. 2004). In the present study students with social phobia had lower scores on all areas of life quality than those without social phobia (Table 6). Students with a specific social phobia had significantly higher quality of life scores in psychological and social areas than those with generalized social phobia. The effects of social phobia on quality of life have not been previously investigated in Turkey. Results of an epidemiological study from Canada that included 8000 people aged years reported that social phobia caused an important decrease in quality of life in all the areas. Participants with generalized social phobia had lower quality of life scores compared to those with a specific social phobia, such as fear of public speaking (Stein and Kean 2000b). A retrospective study that investigated the effects of social phobia on academic achievement and dropping out of school reported that the majority of students that dropped out of school had primary or comorbid social phobia (Van Ameringen et al. 2003). The most common reasons for dropping out of school were feeling anxious while speaking in front of the class and high levels of anxiety in school settings. It was suggested that lack of recognition and early intervention for these students in the school setting caused them to engage in avoidant behavior, constantly experience high levels of anxiety, and eventually drop out of school. Stein and Kean (2000b) reported that students aged years with social phobia were more likely to fail an academic year(1.77%). There was a strong relationship between social phobia type and failing an academic year More participants with generalized social phobia failed an academic year than those with a specific social phobia (1.87%). The results of the present study show that there weren t any negative effects of social phobia on academic achievement; however, this was a cross-sectional study and all the data on students academic achievement could not be obtained. As such, longitudinal, prospective, or retrospective studies could provide us more relevant data. Although it has been ignored for long periods, social phobia can be seen in 1-2 of every 10 university students, and with appropriate interventions it is treated successfully. It is important that families, teachers, and academicians become aware of social phobia, in an effort to identify such students and direct them towards appropriate treatment. Specific and generalized social phobia should be treated as 2 subtypes of social phobia, which have some similarities, as well as differences. Specific social phobias, which involve situations that require performance, is more prevalent among university students. In all, 73.7% of the students in the present study with social phobia had a specific social phobia. An interactive, student-centered educational system could decrease performance anxiety associated with public speaking, which is very common among students with social phobia. Social phobia and identity formation are related topics because of the period in which social phobia emerges and its societal, personal causes. Groups with a high risk for developing 7

8 social phobia, such as women, people living in villages/towns for a long time, people with a family history of psychiatric illness, and people of low socioeconomic status should be monitored more carefully and treated. When risk factors are taken into account, we think that inequalities between social classes also play a role in the emergence of social phobia. We think that as inequalities between different social classes decrease, social anxiety will also decrease. In conclusion, social phobia did not negatively affect academic achievement in the present study, but it negatively affected the students quality of life. REFERENCES Bella TT, Omigbodun OO (2009). Social phobia in Nigerian university students: prevalence, correlates and co-morbidity. Soc Psych Psych Epid, 44: Boone ML, McNeil DW, Masia CL et al. (1999) Multimodal comparisons of social phobia subtypes and avoidant personality disorder. J Anxiety Disord, 13: Çuhadaroğlu F (1999) Identity confusion and depression in groups of adolescents having psychiatric and physical symptoms. The Turkish Journal of Pediatrics 41; Dereboy F (1993). Kimlik bocalaması: anlamak, tanımak, ele almak. Özmert Ofset. Dereboy İF, Dereboy Ç, Çoşkun A et al. (1994). Özdeğer duygusu, öz imgesi ve kimlik duygusu-ii. Çocuk ve Ergen Ruh Sağlığı Dergisi, 1: Dereboy İF, Dereboy Ç, Sevinçok L et al. (1999) Gençlerde kimlik gelişimi sürecini değerlendirmekte kullanılan iki ölçeğin psikometrik özellikleri: karşılaştırmalı bir çalışma. Turk Psikiyatri Derg,10: Dilbaz N, Güz H (2001a) Sosyal anksiyete bozukluğunun fenomenolojisi. Anksiyete Bozuklukları. Bilimsel Çalışma Birimleri Dizisi. Tükel R, Alkın T (ed), 4: Dilbaz N, Güz H (2001b) Liebowitz sosyal kaygı ölçeğinin geçerlik ve güvenirliği. 37. Ulusal Psikiyatri Kongresi, İstanbul, 2-6 Ekim, Dilbaz N (2002) The prevalence of social phobia among the Turkish university students. XII. World Con gress of Psychiatry, Yokohama, August 24-29, Eng W, Heimberg RG, Coles ME et al. (2000) An empirical approach to subtype identification in individuals with social phobia. Psychol Med, 30: Eser E, Fidaner H, Fidaner C et al.. (1999) WHOQOL-100 ve WHOQOL BREEF in psikometrik özellikleri. 3P Dergisi; Francis G, Last CG, Strauss CC (1992)Avoidant disorder and social phobia in children and adolescents. J Am Acad Child Adolesc Psychiatry, 31: Furmark T, Tillfors M, Everz P-O et al. (1999) Social phobia in the general population: prevalence and sociodemographic profile. Soc Psych Psych Epid, 34: Ham LS, Hope DA (2005) Incorporating social anxiety into a model of university student problematic drinking. Addict Behav, 30: Heimberg RG, Holt CS, Schneier FR et al. 1993) Spitzer RL. The issue of subtypes in the diagnosis of social phobia. J Anxiety Disord, 7: Heimberg RG, Stein MB, Hiripi E et al. (2000) Trends in the prevalence of social phobia in the United States: a synthetic cohort analysis of changes over four decades. Eur Psychiatry, 15: İzgiç F, Akyüz G, Doğan O et al. (2000) Üniversite öğrencilerinde sosyal fobi yaygınlığı. Anadolu Psikiyatri Dergisi, 1(4): Izgiç F, Akyüz G, Doğan O et al.(2004) Social phobia among university students and its relation to self-esteem and body image. Can J Psychiatry, 49: Johnson JG, Cohen P, Pine DS et al. (2000) Association between cigarette smoking and anxiety disorder during adolescence and early adulthood. JAMA, 284: Kessler RC, McGonagle KA, Zhao S et al. (1994) Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Arch Gen Psych, 51:8 19. Kessler RC, Stein MB, Berglund P (1998) Social phobia subtypes in the National Comorbidity Survey. Am J Psychiatry 155: Kessler RC, Stang P, Wittchen HU et al. (1999) Lifetime comorbidities between social phobia and mood disorders in the US National Comorbiditiy Survey. Psycol Med, 29: Kılıç C (1997) Türkiye Ruh Sağlığı Profili: Erişkin Nüfusla İlgili Sonuçlar. Türkiye Ruh Sağlığı Profili, Ön Rapor. Erol N, Kılıç C, Ulusoy M, Keçeci M, Şimşek ZT (ed.) Ankara, Aydoğdu Ofset, T.C. Sağlık Bakanlığı. Kırpınar İ, Özer H, Coşkun İ et al. (1997) Erzurum daki üniversite öğrencilerinde CIDI (DSM-III-R) ruhsal bozuklukların yaşam boyu ve 12 aylık yaygınlığı. PPP Dergisi, 4: Last CG, Perrin S, Hersen M et al. (1992) DSM-III-R anxiety disorder in children: sociodemographic and clinical characteristics. J Am Acad Child Adolesc Psychiatry, 31; Liebowitz MR (1987) Social phobia. Mod Probl Pharmacopsychiatry 22: Mennin DS, Heimberg RG, Jack MS (2000). Comorbid generalized anxiety disorder in primary social phobia: symptom severity, functional impairment, and treatment response. J Anxiety Disord, 14: Safren SA, Heimberg RG, Brown EJ et al. (1997) Quality of life in social phobia. Depress Anxiety, 4: Sareen J, Cox BJ, Afifi TO et al. (2005) Anxiety disorders and risk for suicidal ideation and suicide attempts. Arch Gen Psychiat, 62: Schneier FR, Johnson J, Hornig CD et al. (1992) Social phobia. Comorbidity and morbidity in an epidemiologic sample. Arch Gen Psychiat, 49: Solmaz D, Gökalp PG, Babaoğlu AN (1999) Sosyal fobide klinik özellikler ve eş tanı. Turk Psikiyatri Derg, 10: Sonntag H, Wittchen HU, Höfler M et al. (2000) Are social fears and DSM-IV social anxiety disorder associated with smoking and nicotine dependence in adolescents and young adults? Eur Psychiatry, 15: Stein MB, Torgrud LJ, Walker JR (2000a) Social phobia symptoms, subtypes, and severity: findings from a community survey. Arch Gen Psychiat, 57: Stein MB, Kean YM. (2000b) Disability and quality of life in social phobia: epidemiologic findings. Am J Psychiat, 157: Stein MB, Fuetsch M, Müler N et al. (2001) Social anxiety disorder and the risk of depression: a prospective community study of adolescents and young adults. Arch Gen Psychiat, 58: Tillfors M, Furmark T.(2007) Social phobia in Swedish university students: prevalence, subgroups and avoidant behavior. Soc Psych Psych Epid, 42: Türkbay T, Özcan C, Doruk A et al. (2005) Consequences of identity confusion on adolescents psychiatric symptoms and self-esteem. Psychiatry in Turkiye, 7: Van Ameringen M, Mancini C, Farvolden P. (2003) The impact of anxiety disorders on educational achievement. J Anxiety Disord, 17: Vriends N, Becker ES, Meyer A. et al. 2007) Subtypes of social phobia: are they of any use? J Anxiety Disord, 21: Wilson I. (2005) Screening for social anxiety disorder in first year university students. A pilot study. Aus Fam Physican, 34: Wittchen HU, Stein MB, Kessler RC. (1999) Social fears and social phobia in a community sample of adolescents and young adults: prevalence, risk factors and co-morbidity. Psychol Med, 29: Wittchen HU, Fehm L.(2001) Epidemiology, patterns of comorbidity, and associated disabilities of social phobia. Psychiatr Clin N Am, 24: